Cervical Spine. New Patient Form

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1 Cervical Spine New Patient Form

2 Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right Left

3 Date Name Referred by Age Date of Birth Gender: Major complaint Enter the percentage of pain (from 1% to 100%) for each area (the sum should be 100%) Neck: % Arms (including hands): % Mark the degree of pain with an X on the lines below (Indicate the least and the worst pain, as well as the average amount of pain) Neck Arms Hands Head When did symptoms start? How did symptoms start? Do you feel any numbness? Do you feel any tingling? Do you have any weakness? Left arm Right arm Left leg Right leg Left arm Right arm Left leg Right leg Left arm Right arm Left leg Right leg What tests have been done on your neck or back in the last year: X-rays MRI CT Scan Myelogram EMG Discogram CT Myelogram Neurogram Bone density study

4 I have tried: (1) Physical therapy Not helpful Helpful (2) Stretching Not helpful Helpful (3) Exercises Not helpful Helpful (4) Acupuncture Not helpful Helpful (5) Chiropractors Not helpful Helpful (6) TENS Unit Not helpful Helpful (7) Traction Not helpful Helpful (8) Medications Not helpful Helpful (9) Epidural injection Not helpful Helpful Duration of effect (10) Facet injection Not helpful Helpful Duration of effect (11) SI (sacroiliac) injection Not helpful Helpful Duration of effect (12) Radiofrequency ablation (RFA) Not helpful How do the following activities usually affect your pain? Helpful Duration of effect Sitting Relieves pain Worsens pain No effect Standing Relieves pain Worsens pain No effect Walking Relieves pain Worsens pain No effect Lying on my side Relieves pain Worsens pain No effect Lying on my back Relieves pain Worsens pain No effect Lying on my stomach Relieves pain Worsens pain No effect Leaning forward (as with brushing teeth) Relieves pain Worsens pain No effect Bending forward Relieves pain Worsens pain No effect Bending backward Relieves pain Worsens pain No effect Driving Relieves pain Worsens pain No effect Coughing or sneezing Relieves pain Worsens pain No effect How long can you do the following without pain? Sit minutes hours no restriction Stand minutes hours no restriction Walk minutes hours no restriction

5 Neck Disability Questionnaire Please circle one best answer per section. SECTION 1 - Pain Intensity 1. I have no pain at the moment. 2. The pain is very mild at the moment. 3. The pain is moderate at the moment. 4. The pain is fairly severe at the moment. 5. The pain is very severe at the moment. 6. The pain is the worst imaginable at the moment. SECTION 2 - Personal Care (Washing, Dressing, etc.) 1. I can look after myself normally without causing extra pain. 2. I can look after myself normally, but it is very painful. 3. It is painful to look after myself and I am slow and careful. 4. I need some help, but manage most of my personal care. 5. I need help every day in most aspects of self-care. 6. I do not get dressed, wash with difficulty and stay in bed. SECTION 3 - Lifting 1. I can lift heavy weights without extra pain. 2. I can lift heavy weights, but it gives extra pain. 3. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned 4. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. 5. I can lift very light weights. 6. I cannot lift or carry anything at all. SECTION 4 - Reading 1. I can read as much as I want to with no pain in my neck. 2. I can read as much as I want to with slight pain in my neck. 3. I can read as much as I want to with moderate neck pain 4. I cannot read as much as I want due to moderate neck pain 5. I cannot read as much as I want due to severe neck pain 6. I cannot read at all. SECTION 5 - Headaches 1. I have no headaches at all. 2. I have slight headaches which come infrequently. 3. I have moderate headaches which come infrequently. 4. I have moderate headaches which come frequently. 5. I have severe headaches which come frequently. 6. I have headaches almost all the time. SECTION 6 - Concentration 1. I can concentrate fully when I want to with no difficulty. 2. I can concentrate fully when I want to with slight difficulty. 3. I have a fair degree of difficulty in concentrating when I want to. 4. I have a lot of difficulty in concentrating when I want to. 5. I have a great deal of difficulty in concentrating when I want to. 6. I cannot concentrate at all. SECTION 7 - Work 1. I can do as much work as I want to. 2. I can only do my usual work, but no more. 3. I can do most of my usual work, but no more. 4. I cannot do my usual work. 5. I can hardly do any work at all. 6. I cannot do any work at all. SECTION 8 - Driving 1. I can drive my car without any neck pain. 2. I can drive my car as long as I want with slight pain in my neck. 3. I can drive my car as long as I want with moderate pain in my neck. 4. I cannot drive my car as long as I want because of moderate pain in my neck. 5. I can hardly drive at all due to severe neck pain 6. I cannot drive my car at all. SECTION 9 - Sleeping 1. I have no trouble sleeping. 2. My sleep is slightly disturbed (less than 1 hour sleepless). 3. My sleep is mildly disturbed (1-2 hours sleepless). 4. My sleep is moderately disturbed (2-3 hours sleepless). 5. My sleep is greatly disturbed (3-5 hours sleepless). 6. My sleep is completely disturbed (5-7 hours). SECTION 10 - Recreation 1. I am able to engage in all of my recreational activities with no neck pain at all. 2. I am able to engage in all of my recreational activities with some pain in my neck. 3. I am able to engage in most, but not all of my recreational activities because of pain in my neck. 4. I am able to engage in a few of my recreational activities because of pain in my neck. 5. I can hardly do any recreational activities because of pain in my neck. 6. I cannot do any recreational activities at all.

6 Review of Systems In the past month I have had (mark anything that applies): General 1. Fever 2. Chills 3. Unexplained weight loss 4. Night sweats 5. Fatigue 6. Loss of appetite Neurological 7. Numbness 8. Dizziness 9. Tingling 10. Tremors 11. Dyscoordination 12. Migraines 13. Headaches 14. Memory problems Musculoskeletal 15. Joint pain 16. Joint stiffness 17. Joint swelling 18. Joint redness Pulmonary 19. Cough 20. Shortness of breath 21. Wheezing Cardiac 22. Chest pain at rest 23. Chest pain with activity 24. Irregular heartbeat Gastrointestinal 25. Abdominal pain 26. Diarrhea 27. Constipation 28. Incontinence 29. Blood in stool 30. Heartburn 31. Pain with bowel movement Urological 32. Pain with urination 33. Blood in the urine 34. Cloudy urine 35. Incontinence 36. Increased urgency 37. Increased frequency Skin 38. Rash 39. Itching 40. Discoloration Ear/ Nose/ Throat 41. Difficulty swallowing 42. Hoarseness 43. Voice changes Extremities 44. Leg pain with walking 45. Cold hands 46. Cold feet Psychological 47. Frequent crying 48. Insomnia 49. Depression 50. Anxiety 51. Hearing voices 52. Hallucinations Other: Are you under a doctor s care for any medical condition? Yes No Please list all the other physicians you have consulted with over the past year:

7 Social Summary Currently I am: (1) Working full-time (2) Working part-time (3) Student (4) Unemployed (5) Homemaker (6) Retired (7) On disability If not currently working, when did you last work? What is your job title? What exercise or athletic activities do you participate in? Currently I am: (1) Married (2) Partnered (3) Divorced (4) Single How many children do you have? (5) Widowed What is your height? What is your weight? I have lost or gained in the last six months. Will there be a lawsuit or litigation regarding your injury? Yes No Is this injury work related? Yes No If this is a work injury, please answer the following questions: Is there a workers compensation claim? Yes No If yes, what was the date of injury? Please describe this injury: How much time do you spend doing the following on the job per day? Driving Sitting Walking Standing Bending Lifting

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